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Medicaid Claims Specialist
2 months ago
Position: Medicaid Claims Specialist
Work Schedule: Monday to Friday, 8:00 AM to 5:00 PM - Hybrid model with in-office requirements on select days.
Employment Type: Temporary to Permanent, contingent upon performance and business needs.
Key Qualifications:
- Demonstrated experience in Medicaid claims processing within the pharmaceutical or medical device sectors, or relevant consulting roles.
- A minimum of 2 years of experience in healthcare settings focused on pharmaceuticals, particularly in Medicaid claims management, data analysis, and conflict resolution.
- Proficiency in Revitas/Flex Medicaid systems and advanced skills in Microsoft Excel.
- Exceptional organizational skills with a keen attention to detail, ensuring high accuracy in data handling and reviews.
Role Summary:
- The Medicaid Claims Specialist will oversee the Medicaid Drug Rebate process, which entails validating, verifying, and disputing claims as necessary, along with processing payments for designated state Medicaid agencies and supplemental rebate programs. The specialist is responsible for ensuring timely submissions that comply with CMS regulations and client agreements.
- This role will also involve assisting in dispute resolution, conducting weekly payment runs, supporting SOX audits, and performing ad hoc analyses.
Primary Responsibilities:
- Collaborate with assigned states to obtain Medicaid summary invoices and data files quarterly, ensuring the completeness of the information received. Upload data into Medicaid systems and authorize transactions while documenting any discrepancies and conducting research.
- Perform initial quality checks on summary data for all claim submissions to confirm rebate eligibility and data consistency. (20% of time)
- Validate Claim Level Detail by reviewing questionable claim records and determining if disputes are warranted. (20% of time)
- Resolve disputes and recommend payment amounts for historical outstanding claims submitted with Medicaid. This requires independent judgment on state disputes and ensuring accurate application of CMS codes. (20% of time)
- Conduct Medicaid analyses and prepare documentation for assigned states/programs, communicating key findings and changes to management. (10% of time)
- Provide support to Medicaid team members as needed and collaborate to establish best practices within the Medicaid operations. (5% of time)
- Ensure thorough quality checks on summary data and conduct validations as required. (5% of time)
- Complete necessary analyses and documentation, sharing insights with management. (5% of time)
Educational Background:
- A Bachelor's degree or an equivalent combination of experience and training in a related field.
- Required Experience: Prior Medicaid claims processing experience in the pharmaceutical or medical device industry, or equivalent roles.
- Preferred Experience: At least 2 years in a healthcare environment with a focus on pharmaceuticals, Medicaid claims processing, data manipulation, and system implementation.
- Technical Skills: Familiarity with Model N or Revitas/Flex Medicaid systems and advanced Excel capabilities.
- Knowledge of CMS Medicaid regulations and state-specific issues, including current Medicaid validation rules.
- Strong organizational skills and attention to detail, ensuring high accuracy in data processing.
Industry Knowledge: Familiarity with Medicaid, government pricing, and rebate processes within the pharmaceutical sector is preferred.
Travel Requirements: Minimal travel expected.
Core Competencies:
- Analytical Skills: Ability to analyze and interpret data to resolve complex issues.
- Self-Development: Commitment to personal and professional growth.
- Interpersonal Skills: Ability to build strong relationships with clients and colleagues.
- Planning and Organization: Strong ability to prioritize tasks and meet deadlines.
- Technical Proficiency: Solid understanding of accounting principles and advanced data management skills.
